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0 UNIFIED PROGRAM CONSOLIDATEb FORMV(0nefo==LLsn ( j UNDERGROUND STORAGE TANK 11v� �G OPERATING PERMIT APPLICATION- TANK INFORMATI C31. OF ACTION (Check one item only. Fo+an UST pcInnocent closure or removal, complete only this section and Sections I, II, III, IV, end IXbelow) 1. NEW PERMIT - So 3. RENEWAL PERMIT ❑. 5. CHANGE OF INFORMATION V 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE S. UST REMOVAL \ DATE UST PERMANENTLY CLOSED: 4L? J j 1501 DATE EXISTING UST DISCOVERED: .. 43% .: _. - 77 (A FACILITY ID # # (Agenry BUSINESS NAME (Same as FACILITY NAME or DBA•Doing Busircss As) S ✓J.J J dpi .✓ t .t s J 7 3 BUSINESS SrrE ADDRESS A� im CrrY IN TANK ID # 432 /y' TA��N§s�2K.'MAN�I)fIFACl•()RER 433 TANK CONFIGURATION THIS TANK IS G �I�/✓ / ❑ I. 434 T f/��\ n/ c) D C/N/U�J II A STAND-ALONE TANK ONE IN A \ 1 (/ 4/ COMPARTMENTED UNIT. DATE UST SYSTEM STALLED 433 Cnn tame fa ea,he rntin Ox: unit TANK CPo rrry nr r r r 1ue 432 pp "U ]'S IN THE 1T 437 TANK USE Is. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (hsludn Used Ofl) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25291.5(,)] ❑ 1. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑' 99. OTHER (Specify): CONTENTS PETROLEUM: Ia. REGULAR UNLEADED ❑ Ic. MIDGRADEUNLEADED ❑ It. PREMIUM UNLEADED �. 439Y 440 S DIESELLE.JEI'FUEL ❑ S. AVIATION GAS e. PETROLEUM BLEND FUEL . OWER PETROLEUM (Specify); I � s J 11NON-PETROUM: (f f ❑ 7. USED 0 L ID. ETHANOL 14u 11.0THERN0N-PETR0LEUMS ec 440b 1 TTRE upL SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN PRIMAR CON PRIMARY CONTAINMENT ❑ 1. STEEL•pIBERGLASS ❑ 6.IMERNAL BLADDER d43 ❑ 7. STEEL +INTERNAL LINDIG ❑ 95. UNKNOWN ❑ 99. OTHER S 444 ci SECONDARY CONTAINMENT ❑ 1. STEEL .FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINEA ❑ 7. IACKETED 2442 445 ❑ 90. NONE - ❑ 95. UNKNOWN ❑ 99.OTHER S eci OVERFILL PREVENTION . AUDIBLE &VISUAL ALARMS 2. BALL FLOAT J. FILL TUBE SHUT-OFF VALVE a5a 45x. ❑ 4. TANK MEETS REQUIREMENTS FOR EXF1dPT10N FROM OVERFILL PREVENTION EQOIPMENT �f PIPING CONSTRUCTION ❑ 1. SINGLE -WALLED 2. DOUBLE -WALLED ❑ 99 OTHER,^ .c SYSTEM TYPE ❑ 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION nCCR 2656(2 3 460 458 PRIMARY CONTAINMENT Jfr4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER( Spechy): SECONDARYCONTAINMENT ❑ I. STEEL 4. FIBERGLASS C]B. FLEXIBLE ❑ 10. RIGID PLASTIC yp2 4Mb ❑ 90. NONE ❑ 95.UNKNOWN 1399. OTHER (Specify): 4", PIPINGfTURBINE CONTAINMENT SUMP TYPE ❑I. SINGLEWALL +DOUBLE WALL ❑90. NONE 4644 y VENT PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS I0. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464, VENT SECONDARY CONTAINMENT LSIEEL -FIBERGLASS 1 10. RIGID PLASTIC 9 0. NONE 99. OTHER(Specify) 4464r VR PRIMARY CONTAINMENT 1.5 1 EEL .FIBERGLASS 10: RIGID PLASTIC90. NONE 99. OTHER (Specify) 464, VR SECONDARY CONTAINMENT I. STEEL .FIBERGLASS I0. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464 I 4MI, VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL464h1 . OUBLE WALL 90'.NONE 464i. RISER PRIMARY CONTAINMENT .STEEL 4. FIBERG . SSS 10. RIGID PLASTIC 90. NONE 99. OMER (Specify) 464' RISER SECONDARY CONTAINMENT . STEEL 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99.OTHERS OTHER(Specify) 461k FILL COMPONENTS INSTALLED 7. SPILL BUCKET 3. STRIKER PLATF/BOTTO 4 PROTECTOR 4. CONTAINMENT SUMP 4Mk I 451st CONSTRUCTION TYPE ❑ 1. SINGLE WALL 9;-lDOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 46% CONSTRUCTION MATERIAL 1. STEEL 4. FIBERGLASS 0. RIGID PLASTIC ❑99.OTHER S eci 4696 p STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑1 4. IMPRESSED CCUUaYYRRENT6. ISOLATION 448, CERTIFICATION: I certify that this UST system is compatlble with the haaardoto substance stored and that the information provided herein Is true, accurate, and In full co ante with les a uirementa. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) °TI' APPLICANTT 4n. A� / C !L m�✓.1E�- UPCF UST -B -1/2' Rev. (128007)